The proposed project is designed to fill an extremely important yet unmet need by developing an alternative training mechanism that has the potential for reaching all personnel responsible for risk management and quality improvement in programs that provide services to persons with mental retardation/developmental disabilities (MRDD) and the public agency staff that oversee such programs. Pursuing this objective, the applicant organization, Praxis, Inc., and Eunice Kennedy Shriver Center at the University of Massachusetts Medical School will work together to develop skills and competencies in conducting root cause analysis (RCA), a recognized best practice approach to reducing adverse events. The skill development will be an "anytime, anywhere" training program available to anyone with Internet access. The program, RCA/DD, is intended to meet the essential needs of public and private agencies to assure the health, safety and welfare of a very vulnerable population that is at increased risk of harm and that is being served in over 145,000 residential settings across the nation, a basic assurance all public agencies must meet to receive federal HCBS and ICF/MR funding. Course work will teach contemporary, evidence-based methods and procedures in RCA specifically adapted to the unique nature of MRDD services. The product, RCA/DD will be a fully hosted, Web-based distance learning instructional program in which lessons will build upon 1 another, assisting learners to acquire a foundation of knowledge upon which more complex skill sets can be built. Learners who participate in RCA/DD will apply knowledge acquired through their readings to simulated or real life situations and adverse events that commonly occur in service settings serving the MRDD population. Self-assessments will be built into each module to help them accurately and systematically assess their skills and develop learning plans to improve when needed. [unreadable] [unreadable] [unreadable]